A systems approach to understanding the identification and treatment of sport-related concussion in community rugby union

Non-reporting of sport-related concussion symptoms: a cross-sectional study of community rugby league players in the UK

Recognising and removing players with suspected sport-related concussions is crucial for community sports.

OBJECTIVES

Quantify rates and factors associated with non-reporting of concussion symptoms in community rugby league.

METHODS

Overall, 484 community rugby league players aged ≥18 years and 965 parents of rugby league players aged <18 years completed an online survey, regarding concussion history, knowledge, prevalence and reasons for non-reporting of concussion, long-term implications and perceptions of concussion.

RESULTS

Thirty-five percent of players aged ≥18 years and 22% of parents of players aged <18 years reported at least one concussion in the last two seasons. Forty-three percent of players aged ≥18 years and 5% of parents of players aged<18 years surveyed stated they did not report concussion-related symptoms sustained during 2020 and 2021 seasons. The two most common reasons for non-reporting of concussion symptoms were 'didn't want to be ruled out of a match' and 'didn't want to let down the team'. Players aged ≥18 years who received external coaching pressures around concussion were more likely to not report concussion symptoms. Over 40% of parents and players were concerned about the potential long-term implications. Ten percent of players aged ≥18 years and 7% of parents of players aged <18 years would encourage their family members/children to not play rugby league.

CONCLUSIONS

Non-reporting rates of suspected concussion symptoms in adult community players were twice as high as in professional rugby league, with similar reasons (wanting to play and not letting the team down). Engaging coaches to prioritise brain health and providing broader and appropriate education on concussion should be focused on, given the concerns reported by community players and parents.

An examination of social relations and concussion management via the blue card

Introduction

Initially developed by New Zealand Rugby in 2014, the Blue Card initiative in rugby enables match officials to remove athletes from play if they are suspected to have sustained a concussion. Considerable attention has been paid by sport and health advocates to the possibilities and limitations of this initiative in safeguarding athlete health. However, little if any attention has been paid to the well-being of those responsible for administering the Blue Card (i.e., match officials). The aim of this paper was to examine match officials' experiences with and perspectives on implementing the Blue Card initiative in Ontario, Canada, with focused attention on the tensions around their ability to manage games and participants (e.g., athletes, coaches) while attempting to safeguard athlete well-being.

Methods

Using Relational Coordination Theory (RCT) as a guiding framework and qualitative research method, we highlight the rich accounts of 19 match officials' perspectives and experiences regarding sport-related concussion (SRC) management and the Blue Card protocol.

Results

Four themes were derived from the data, reflecting latent assumptions embedded within the concussion management process, which include: assumptions of trust, respect, and cooperation; assumptions of shared responsibility; assumptions of shared understanding; and assumptions of harassment-free sport.

Discussion

Our findings emphasize the need to attend to social relations in concussion management and provide insight into match officials' fraught experiences on the frontlines of concussion management. We identify factors affecting match official well-being and provide considerations for concussion management initiatives designed to improve athlete safety, such as the Blue Card.

What Enables Child Sexual Abuse in Sport? A Systematic Review

Sporting environments provide opportunities for perpetrators to commit child sexual abuse (CSA). While awareness of CSA in sport and preventative interventions are increasing, CSA in sport still occurs at alarming rates. A systematic review was conducted to identify and synthesize the extant literature on the enabling factors for CSA in sport. The 34 included articles were peer-reviewed and were primary sources; had full-text versions in English; included the individual, situational, environmental, or systemic antecedent factors and characteristics which enable CSA in organized sport (clubs, schools, universities, and representative teams); and focused on abuse in children (0-18 years old), and included retrospective incidents. The enabling factors from across the broader sports system were identified and mapped using a systems thinking-based approach, the Risk Management Framework (RMF) and the associated AcciMap method. The results indicated that enabling factors for CSA in sport were identified at multiple levels of the sporting system hierarchy. The results show that 24.1% (n = 46) of the enabling factors identified in the literature relate to the hierarchical level of the Athlete, teammates, opponents, and fans levels, and 52.9% (n = 101) of the enabling factors relate to the level of Direct supervisors, management, medical, and performance personnel level. However, only 13% (n = 25) of enabling factors to CSA in sport were identified at the combined top four hierarchical levels. Results indicate that the problem of CSA in sport is a systems issue, and future research is required to explore how these factors interact to enable CSA in sport.

Applying a systems thinking lens to anti-doping: A systematic review identifying the contributory factors to doping in sport

The use of performance enhancing substances and methods (known as "doping") in sport is an intractable issue, with current anti-doping strategies predominantly focused on the personal responsibility and strict liability of individual athletes. This is despite an emerging understanding that athletes exist as part of a broader complex sports system that includes governance, policymakers, media, sponsors, clubs, team members, and athlete support staff, to name a few. As such, there is a need to examine the broader systemic factors that influence doping in sport. The aim of this systematic review was to identify and synthesise the factors contributing to doping and doping behaviours, attitudes, and beliefs and the extent to which this knowledge extends beyond the athlete to consider broader sports systems. The review followed PRISMA guidelines with risk of bias and study quality assessed by the Mixed Methods Appraisal Tool, and identified contributory factors synthesised and mapped onto a systems thinking-based framework. Overall, the included studies were determined to be of high quality. Support personnel, the coach, and the coach-athlete relationship represent key influences on the athletes' decisions to dope. From the evidence presented, doping is an emergent property of sport systems and represents a complex systemic problem that will require whole-of-system interventions. The implications for this and the focus of future research are discussed.

Quest for clarity: investigating concussion-related responsibilities across the New Zealand Rugby Community System

There is a growing concern around concussions in rugby union, at all levels of the game. These concerns highlight the need to better manage and care for players. However, consistency around concussion-related responsibilities of stakeholders across the community rugby system remains challenging. Taking a systems thinking approach, this pragmatic, qualitative descriptive study explored key stakeholder groups within New Zealand's community rugby system's perceptions of their own and others' concussion-related responsibilities. Participants included players from schools and clubs, coaches, parents, team leads and representatives from four provincial unions. A total of 155 participants (67 females and 88 males) were included in the study. Focus groups and individual interviews were conducted. Thematic content analysis was used to analyse data. Thirty concussion-related responsibilities were identified. These responsibilities were contained within four themes: (1) policies and support (responsibilities which influence policy, infrastructure, human or financial resources); (2) rugby culture and general management (responsibilities impacting players' welfare and safety, attitudes and behaviour, including education, injury reporting and communication); (3) individual capabilities (responsibilities demonstrating knowledge and confidence managing concussion, leadership or role/task shifting) and (4) intervention following a suspected concussion (immediate responsibilities as a consequence of a suspected concussion). The need for role clarity was a prominent finding across themes. Additionally, injury management initiatives should prioritise communication between stakeholders and consider task-shifting opportunities for stakeholders with multiple responsibilities. How concussions will realistically be managed in a real-world sports setting and by whom needs to be clearly defined and accepted by each stakeholder group. A 'framework of responsibilities' may act as a starting point for discussion within different individual community rugby contexts on how these responsibilities translate to their context and how these responsibilities can be approached and assigned among available stakeholders.

Understanding the systemic influences on maritime pilot decision-making

Maritime incidents occurring during pilotage are of international concern. Maritime pilots control most pilotage operations worldwide, yet despite the safety criticality of their role, research examining pilot decision-making processes during these complex and dynamic operations is scarce. This article describes the findings from two studies that utilised an integrated systems thinking framework to understand how pilots make decisions and what factors are perceived to influence their decisions. Interviews were held with 22 pilots (Study 1) and 17 maritime safety stakeholders (Study 2) in the New Zealand maritime context. The findings illustrate the challenges pilots face during pilotage and provide insights into their decision-making processes and the systemic factors that can be addressed to improve maritime safety. Given the multiple causal pathways to incidents occurring during pilotage identified by this research, it is suggested that multiple systems-wide interventions are needed, which is likely to require a long-term, strategic approach.

Mental Toughness Development via Military-Style Training in the NCAA: A Three-Phase, Mixed-Method Study of the Perspectives of Strength and Conditioning Coaches

Sport cultures transmit values for anticipated conduct. Recent events have resulted in injuries/deaths of National Collegiate Athletic Association (NCAA) student-athletes, usually during off-season football training. Through media reports, strength and conditioning coaches (SCC) have been allegedly involved by incorporating military-style training (MST). Mental toughness (MT) has been associated with hypermasculine subcultures in sports. For the first time, perceptions of collegiate SCCs were chosen to contribute to the development of cultural best practices in sports, via a multiphase mixed-method design (Phase 1, n = 465; Phase 2, n = 72; Phase 3, n = 99). Quantitative and qualitative data were collected aiming to confirm and explore the use of MST in the NCAA, its connection to SCCs, its association with MT development, and the role of the media. MST is uncommon in the NCAA. MST takes place mostly during the off-season in the form of physical, in-scope protocols while football is the most common sport. MST promotes MT. The recent media backlash is considered unfounded. Cultures promoted by SCCs do not indicate conformity of student-athletes to unethical/unhealthy expectations. Future sport psychology research and practice should continue to prioritize culture, cultural identities, and physical and mental well-being.

Systems thinking-based risk assessment methods applied to sports performance: A comparison of STPA, EAST-BL, and Net-HARMS in the context of elite women's road cycling

There is increasing interest in applying systems Human Factors and Ergonomics (HFE) methods in sport. Risk assessment (RA) methods can be used identify risks which may impact the performance of individual athletes, teams, and overall sports systems; however, they have not yet been tested in sport. This study sets out to apply and compare three systems thinking-based RA methods in the context of elite sports performance and report on the frequency and types of the risks identified. The Systems-Theoretic Process Analysis (STPA) method, the Event Analysis of Systemic Teamwork Broken Links (EAST-BL) method, and the Networked Hazard Analysis and Risk Management System (Net-HARMS) method were applied to elite women's road cycling to identify all the credible risks that could degrade optimal team performance. The findings demonstrate that all three methods appear to provide useful results in a context other than safety, and that multiple risks threatening the performance of the cycling team were identified. Whilst the frequency and types of risks differed across the methods applied, there are additional theoretical, methodological, and practical implications to be considered prior to the selection and use of systems thinking-based RA approaches. Recommendations and directions for future HFE and sports science research are discussed.

Sports-related concussion management as a control problem: using STAMP to examine concussion management in community rugby

The effective management of sports-related concussion is an on-going problem in amateur sport due to a number of systemic issues. These factors have often been studied in isolation with minimal consideration for the interactions between them, or the overall system in which they occur. The aim of this research was to model the actors, controls, and feedback mechanisms influencing the management of concussion in community rugby union using the Systems-Theoretic Accident Model and Processes (STAMP) method. Findings show that there are currently many inadequate controls, that are directly and indirectly impacting effective concussion management. The practical implications of these findings are discussed (e.g. improved guideline education, mandatory medical presence, rule amendments). Additionally, the model provides a sound framework similar team sports can use to inform research into injury management and prevention (e.g. rugby league, hockey, AFL). Practitioner Summary: Research shows that concussion management in regional sport is inconsistent due to contextual limitations. Systems-Theoretic Accident Model and Processes was applied to identify the systemic factors currently influencing concussion management practices in community sport. Findings show inadequate controls precipitate concussion management gaps. Practical implications of the findings are discussed.